Family Meeting Guideline This guideline presupposes that appropriate communication with the patient has occurred and the principles of patient confidentiality and autonomy/surrogate decision making are followed. See the “Clinical Decision Making (adult patient)” summary in the desktop ethics file. Background: Studies reveal that 40% of the families of critically ill patients do not feel well informed and that the decision making process for their loved one can be confusing. Families are often given brief clinical facts that are incomplete and at times inconsistent. This confusion is harmful to the family and is often the source of anger/mistrust directed at the caregivers. Proactive, timely communication for the families of critically ill patients has been shown to: 1.Reduce family anxiety, depression and PTSD and 2. Result in fewer non-beneficial ICU days and procedural interventions for the patient. Process Recommendations: Steps to consider when arranging a meeting: 1.For families of seriously ill hospitalized patients, it is recommended that a family meeting occur within 72 hours of admission and perhaps sooner if there are untoward events, worsening prognosis, etc. Don’t wait for issues to develop (reactive style) before scheduling a meeting. Advanced meeting planning maximizes the likelihood that effective communication and decision making can occur. 2.Be aware of the importance of cultural factors. Use a qualified, independent, medically trained interpreter for most meetings. Poor communication greatly compromises information sharing. 3.Who should attend? Families prioritize the following participants: 1. the primary treating physician; they prefer to receive information from the physician they see the most. This can be the junior physician on the team. 2. the continuity outpatient physician who knows the patient best (when available). We recommend including key family/friends, the supervising Attending, the Resident Physician, a nurse (who is familiar with the patient and the family when possible), a social worker, and a palliative care representative (if terminal care is likely). Information from consulting specialists is best shared by the primary treating physician. 4.Who should lead the meeting? The primary treating physician should lead the meeting. At CCRMC, the Family Medicine Resident should always be included and can lead the meeting under the supervision of the Attending. This should be decided in advance based on the comfort and experience of the Resident and the Attending. 5.When and where: chose a quiet, uninterrupted space, pagers/cells on quiet mode. Allow 45-60 minutes when major issues/decisions are to be discussed. 6.The “agenda” for the meeting usually includes an introduction by the meeting leader, introduction of all participants, a general statement of the purpose of the meeting (which should include a brief summary of the clinical status of the patient), eliciting the concerns and questions of those involved, determining the family’s style of decision making, discussing and restating options, wrap up/conclusion and follow up plans. Pearls/Pitfalls: 1.Studies reveal that families highly value the following caregiver communication qualities: A. Caregiver willingness to listen. The meeting should include ample time to elicit the family’s concerns as well as their preferred decisional style. e.g. “We want to make sure we know your concerns and questions.” “We like to know how your family makes difficult decisions and how we can best help you.” B.Empathy for the plight of the patient and family. Acknowledge their emotions and the potential loss of a loved one. e.g. “It must be hard to see your sister this way.” “Feeling anger and a loss of control are common in these situations.” C.Respect for the family’s input/preferences. Remember (and acknowledge) that they generally know more than we do about the patient. e.g.. “Tell us a little more about your mother.” “We respect your mother’s wishes and very much want to understand them.” 2.Avoid foregone meeting goals/conclusions: It is best to not have a specific pre-determined goal in mind such as “we’ll achieve DNR status by the end of the meeting”. We all have personal feelings regarding what is best for our patient. Recognize andseparate your own personal goals from the patient and family’s goals. eg. “I wouldn’t want to exist like this.” 3.When dissent occurs among family members and discussion is getting off track, it is important to refocus discussion on the patient’s values and goals. Ask for characteristics of the patient that might shed light on their preferences. e.g. “If your father could talk to us, what do you think would be most important to him?” “Most families have some areas of disagreement, but we need to refocus on what your father would have wanted in this situation.” 4.Families prefer to hear statistical prognosis information as a rough percentage or number. e.g. “His chance of survival is poor, 9 out of 10 patients (or 90%) die when in this condition.” 5.If the prognosis is extremely poor, and the patient is actively terminal, one should state that “your brother is dying”. This can help families to turn their focus to end of life planning. 6.Set a follow-up plan with the family at the conclusion of the meeting. Another meeting should be scheduled for most significant issues. Clarify the best way for the family to contact the team in the days ahead. If certain basic clinical parameters are key factors to follow, state what they are and when they will be known. e.g.: “The CXR and the kidney function test in 24-48 hours will help us to know whether she has responded to therapy.” The concept of a time limited trial can be useful when a family requests continuation of apparently non-beneficial care. 7.Actively relieve the sole burden of decision making by the family. “We will share this difficult decision together with you.” “The decisions we have made together today seem to be the best course of action your father would have wanted.” 8.Consider pledges or promises to reassure the family. “We will never abandon your sister.” “We will be honest with you and share everything we know, both the good and the bad.” 9.When treatment conficts persist, consider consultation with the Bioethics, Palliative Care orMedical Error Adverse Outcome Committee (MEAO). Call schedules are in Amion. Guideline team: Applegate, Barrow, Freedman, Kuravilla-April, 2010
This guideline presupposes that appropriate communication with the patient has occurred and the principles of patient confidentiality and autonomy/surrogate decision making are followed. See the “Clinical Decision Making (adult patient)” summary in the desktop ethics file.
Background: Studies reveal that 40% of the families of critically ill patients do not feel well informed and that the decision making process for their loved one can be confusing. Families are often given brief clinical facts that are incomplete and at times inconsistent. This confusion is harmful to the family and is often the source of anger/mistrust directed at the caregivers. Proactive, timely communication for the families of critically ill patients has been shown to: 1.Reduce family anxiety, depression and PTSD and 2. Result in fewer non-beneficial ICU days and procedural interventions for the patient.
Process Recommendations: Steps to consider when arranging a meeting:
1. For families of seriously ill hospitalized patients, it is recommended that a family meeting occur within 72 hours of admission and perhaps sooner if there are untoward events, worsening prognosis, etc. Don’t wait for issues to develop (reactive style) before scheduling a meeting. Advanced meeting planning maximizes the likelihood that effective communication and decision making can occur.
2. Be aware of the importance of cultural factors. Use a qualified, independent, medically trained interpreter for most meetings. Poor communication greatly compromises information sharing.
3. Who should attend?
Families prioritize the following participants: 1. the primary treating physician; they prefer to receive information from the physician they see the most. This can be the junior physician on the team. 2. the continuity outpatient physician who knows the patient best (when available). We recommend including key family/friends, the supervising Attending, the Resident Physician, a nurse (who is familiar with the patient and the family when possible), a social worker, and a palliative care representative (if terminal care is likely). Information from consulting specialists is best shared by the primary treating physician.
4. Who should lead the meeting?
The primary treating physician should lead the meeting. At CCRMC, the Family Medicine Resident should always be included and can lead the meeting under the supervision of the Attending. This should be decided in advance based on the comfort and experience of the Resident and the Attending.
5. When and where: chose a quiet, uninterrupted space, pagers/cells on quiet mode. Allow 45-60 minutes when major issues/decisions are to be discussed.
6. The “agenda” for the meeting usually includes an introduction by the meeting leader, introduction of all participants, a general statement of the purpose of the meeting (which should include a brief summary of the clinical status of the patient), eliciting the concerns and questions of those involved, determining the family’s style of decision making, discussing and restating options, wrap up/conclusion and follow up plans.
Pearls/Pitfalls:
1. Studies reveal that families highly value the following caregiver communication qualities:
A. Caregiver willingness to listen. The meeting should include ample time to elicit the family’s concerns as well as their preferred decisional style. e.g. “We want to make sure we know your concerns and questions.” “We like to know how your family makes difficult decisions and how we can best help you.”
B. Empathy for the plight of the patient and family. Acknowledge their emotions and the potential loss of a loved one. e.g. “It must be hard to see your sister this way.” “Feeling anger and a loss of control are common in these situations.”
C. Respect for the family’s input/preferences. Remember (and acknowledge) that they generally know more than we do about the patient. e.g.. “Tell us a little more about your mother.” “We respect your mother’s wishes and very much want to understand them.”
2. Avoid foregone meeting goals/conclusions: It is best to not have a specific pre-determined goal in mind such as “we’ll achieve DNR status by the end of the meeting”. We all have personal feelings regarding what is best for our patient. Recognize and separate your own personal goals from the patient and family’s goals. eg. “I wouldn’t want to exist like this.”
3. When dissent occurs among family members and discussion is getting off track, it is important to refocus discussion on the patient’s values and goals. Ask for characteristics of the patient that might shed light on their preferences. e.g. “If your father could talk to us, what do you think would be most important to him?” “Most families have some areas of disagreement, but we need to refocus on what your father would have wanted in this situation.”
4. Families prefer to hear statistical prognosis information as a rough percentage or number. e.g. “His chance of survival is poor, 9 out of 10 patients (or 90%) die when in this condition.”
5. If the prognosis is extremely poor, and the patient is actively terminal, one should state that “your brother is dying”. This can help families to turn their focus to end of life planning.
6. Set a follow-up plan with the family at the conclusion of the meeting. Another meeting should be scheduled for most significant issues. Clarify the best way for the family to contact the team in the days ahead. If certain basic clinical parameters are key factors to follow, state what they are and when they will be known. e.g.: “The CXR and the kidney function test in 24-48 hours will help us to know whether she has responded to therapy.” The concept of a time limited trial can be useful when a family requests continuation of apparently non-beneficial care.
7. Actively relieve the sole burden of decision making by the family. “We will share this difficult decision together with you.” “The decisions we have made together today seem to be the best course of action your father would have wanted.”
8. Consider pledges or promises to reassure the family. “We will never abandon your sister.”
“We will be honest with you and share everything we know, both the good and the bad.”
9. When treatment conficts persist, consider consultation with the Bioethics, Palliative Care or Medical Error Adverse Outcome Committee (MEAO). Call schedules are in Amion.
Guideline team: Applegate, Barrow, Freedman, Kuravilla-April, 2010